Provider Demographics
NPI:1447412184
Name:JAGDALE, DEEPA SANJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:SANJAY
Last Name:JAGDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CSRA PEDS
Mailing Address - Street 2:699 FURYS FERRY RD
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3093
Mailing Address - Country:US
Mailing Address - Phone:706-901-7337
Mailing Address - Fax:706-903-5002
Practice Address - Street 1:699 FURYS FERRY RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9064
Practice Address - Country:US
Practice Address - Phone:706-901-7337
Practice Address - Fax:706-903-5002
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31458208000000X
GA003071208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003161963FMedicaid
SC314582Medicaid